Radiation Therapy as Primary and Adjuvant Treatment for Local and Regional Melanoma

Lawrence B. Berk, MD, PhD


Cancer Control. 2008;15(3):233-238. 

In This Article

Adjuvant Nodal Radiation Therapy

Hietanen et al[26] reviewed 45 patients with Clark level II–V melanoma who received surgery or radiation therapy to the regional nodes for cutaneous melanoma with 51 patients who did not. There was no difference in recurrence in the nodes or in survival between the two groups. Investigators at the University of Florida[27] reported on 56 high-risk patients receiving adjuvant nodal irradiation. The majority (49 patients) had head and neck primaries; 27 patients were treated at presentation and 29 were treated at nodal recurrence. The 5-year local control rate was 87%. They found no difference in local control between patients treated to 60 Gy in 2-Gy fractions and 30 Gy in 6-Gy fractions.

In a large series on adjuvant radiation therapy for cutaneous melanomas from The University of Texas M. D. Anderson Cancer Center,[28,29,30,31,32] radiation therapy was delivered in 6-Gy fractions twice a week to 30 Gy. The latest update is a 2006 review of all sites (cervical, inguinal, axillary).[33] Indications for nodal irradiation included extracapsular extension, 4 or more nodes positive, a lymph node larger than 3 cm, or recurrent nodal disease. A total of 466 patients were reviewed. The 5-year local control rate was 89%. On multivariate analysis, no clinical or pathologic characteristic was identified that correlated with local failure.

O'Brien et al[34] reported on results from nodal irradiation for head and neck melanoma patients at the Royal Prince Alfred Hospital in Sydney, Australia. Among 143 patients with 152 neck dissections, 52 received adjuvant radiation therapy (33 Gy in 6 fractions over 18 days) and 100 received no adjuvant therapy. The irradiated patients had more advanced disease: 65% had 2 or more positive nodes and 48% had extracapsular spread compared with 40% and 19%, respectively, in the nonirradiated group. Despite this, there was in-field recurrence in only 6.5% of the irradiated patients compared with 19% in the group receiving no adjuvant therapy.

Burmeister et al[35] reported on a Tasman Radiation Oncology Group study (TROG 96-06), a prospective trial of postoperative nodal irradiation for node-positive melanoma patients. A total of 234 patients were enrolled. The radiation was prescribed as 48 Gy in 20 fractions (2.4 Gy per fraction). The in-field recurrence rate was 7%.

Creagan et al[36] published the only randomized trial for nodal irradiation in 1978. Eighty-two patients with trunk or extremity melanoma and biopsy-proven nodal metastases at lymphadenectomy were randomized to observation or radiation therapy. The patients were treated with anterior and posterior fields to receive 1.78 Gy daily fractions to 25 Gy, a 4-week break, and then another 25 Gy in 14 fractions. Patients were accrued from January 1972 to July 1977. Eleven patients were eliminated from analysis because they had participated in another trial. Another 6 patients (5 controls and 1 irradiated patient) did not meet the eligibility requirements. Nine patients (1 control and 8 irradiated patients) were ineligible due to protocol violations. The remaining 56 patients (27 irradiated and 29 controls) were included in the analysis. Twenty-four patients were treated at Mayo Clinic, and 3 were treated at other institutions. The median disease-free interval in the radiation arm was 20 months and 9 months in the controls (P = .07). The median survival was 33 months in the irradiation arm and 22 months for the controls (P = .09). Disease-free interval and survival were improved only for patients with a single positive node. However, after adjustment for covariates such as age and sex, treatment was not significant for either disease-free interval or survival. Three of the 27 patients with radiation therapy recurred in the treatment field, and 1 of 29 control patients recurred in the nodal basin.

TROG is completing a randomized trial of adjuvant radiation therapy, 48 Gy in 20 fractions, for patients with positive node dissections for melanoma.

Investigators at The University of Texas M.D. Anderson Cancer Center[37] also studied whether radiation therapy alone is sufficient for local control of the draining lymphatics of cutaneous head and neck melanomas. With a median follow-up of 5 years, the actuarial local control rate for patients with nodes that were not treated surgically was 93%. This suggests that radiation alone may be adequate for treating the at-risk nodes.

Burmeister et al[17] reported on toxicity in their series of combined adjuvant and primary treatment of nodal metastases. No complications occurred in 69% of the patients. The major complication was edema, seen in 23% of the patients. Ballo et al[38] reported on toxicity during axillary irradiation among patients at M. D. Anderson Cancer Center. Twenty percent developed clinically significant arm edema.

In summary, the available data suggest that adjuvant radiation therapy increases local-regional control after nodal dissection for cutaneous melanomas. There is no clear daily dose effect on the outcome. Furthermore, for clinically node-negative patients, radiation alone may be sufficient for local control of the nodal basins.


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